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Aug 29 08 04:21 p 763-213-0699 763-213+0695 p.4 <br /> Par�el number: �,�,�� �A. ��� System status: (�Compliant ❑Nvncompl'�ant <br /> � (as deterrnined by this Iform) <br /> Soil Separation Compliance and O#her Compliance <br /> Compliance Issue#3 of 4 <br /> , <br /> Dabe of cbseroation: ����"�� Reason iar observation: <br /> This irrforma�ion on this farm does not expire. <br /> Compliance questionslcriteria: (Required) Ve�i�cation Method"*:(Optional) <br /> Check lhe a ro ate box (Check the apprapriate 6ox) <br /> For systems built prior to April 1, 1996,and not ('� Conducted sail observation(s)(attach boring Iogs) <br /> located in Shoreland or Wellhead Protection <br /> Area or not serving a food,beverage or ❑ Two previous verifications(attach boring logs� <br /> lodging establishrnent: ❑ Othe�: <br /> Does the system have at Ieas1 a lwo-foot <br /> veNical separation distance from pe�iodically <br /> saturated sail or bedrock? Yes No <br /> For non-performance systems buittApril 1, <br /> 1996.or later or for non-performance systems Soil observation does not expire.Previous observations <br /> bcated in Shoreland or Wellhead Protection by�,�ro independent parties are sufficient,unless site <br /> Areas or serving a food, beverage or lodging conditions have been altered. <br /> establishrnent: <br /> Does the system have a three-Foot vertical <br /> separation distance from periodically saturated <br /> soil or bedrock?' Yes No <br /> For reduced separation d�stance systems(i.e., <br /> "performance"systems under old 7080.0179 or ' May be reduced by up to 15 percent i�allowied in local <br /> Type IV ar V system under�ew 708�. 2350 or or+dinance. <br /> 7080.2400): •'No standerd protoco!exists. This list is not exhaustive, <br /> Ooes the system meet the designed vertical in sequentia/ord�,nor does it lnd/cate whkh <br /> separation distance f�om periodically saturated � combinations are nec:essary to make this <br /> soil or bedrxk?` � ❑Yes ❑No determinafion. <br /> Any'�o"answrrindicates fha!the system is tailrng fo profect <br /> ground water. <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesuta Pollution Control Agency's(MPCA)Compliance <br /> Inspection Form for Existing Subsu�face Sewage Treatment Systems. Observations, interpretations,ar�d condusions must be <br /> completed by an inspector or designer.Completed form must be submitted to Ihe local unit of govemment within 15 days. <br /> Property owner name{s): (J 6� �� <br /> Property address: ��� � 6? �v � <br /> Property owner's address(it different): �/ <br /> County: �Q./)7n�� __ Phone: ����y� •-��d`ti <br /> 1 hereby certify tha�f persona!!y made the observetions, interpretations.and conclusions reported on this torm and fhat they are <br /> correct. <br /> Name: _ 9 Certification number: _��� <br /> Business ' nse name and n�mber: ���_��� �� � � or <br /> Name of local unit of government: <br /> Signatu�e: . ..__ Dete: ._�„���-'n� <br /> — ��� <br /> . .__.......— <br /> wq•wwists4-3i Complionce lnspection Fo�m for Exist�ng SSTS . <br /> 411/OS <br />